Prosthetic Heart Valves Treatment & Management
- Author: Eric M Kardon, MD, FACEP; Chief Editor: Richard A Lange, MD, MBA more...
Emergency Department Care
In patients with acute valvular failure, diagnostic studies must be performed simultaneously with resuscitative efforts.
Primary valve failure
Patients with valvular failure due to breakage or abrupt tearing of the components usually present with acute hemodynamic deterioration. They need emergent valve replacement. Adjunctive therapy may be initiated while these arrangements are being made. A less dramatic presentation of valvular failure may be seen in patients with valve thrombosis or in those with more gradual deterioration of bioprosthetic valves (see Thromboembolic complications).
Begin afterload reduction and inotropic support in order to reduce the impedance to forward flow and improve peripheral perfusion. If the mean arterial pressure is higher than 70 mm Hg, sodium nitroprusside may be used. If the mean arterial pressure is lower than 70 mm Hg, dobutamine alone or in combination with inamrinone may be used.
Avoid inotropic agents with vasoconstricting properties.
Intra-aortic balloon counterpulsation may be useful in cases of acute mitral regurgitation when the patient is in extremis and surgical facilities are not immediately available. Intra-aortic balloon counterpulsation is relatively contraindicated in the presence of an incompetent aortic valve.
Prosthetic valve endocarditis
Administer intravenous antibiotics as soon as 2 sets of blood cultures are drawn. Vancomycin and gentamicin may be used empirically pending blood cultures and determination of methicillin resistance.
Patients taking warfarin who develop PVE should stop until CNS involvement is ruled out and invasive procedures are determined to be unnecessary.
Consider anticoagulation in PVE, since the incidence of systemic embolization is as high as 40%.
Consider emergency surgery in patients with moderate-to-severe heart failure or in patients with an unstable prosthesis noted on echocardiography or fluoroscopy.
Patients presenting with embolization need to be anticoagulated if they are not already taking anticoagulants or have a subtherapeutic INR.
Assessment of valve function is needed.
The RE-ALIGN trial evaluated the safety and efficacy of dabigatran in patients with bileaflet mechanical prosthetic heart valves (recently implanted or implanted more than 3 months prior to enrollment). Patients were randomized to dose-adjusted warfarin or dabigatran 150, 220, or 300 mg BID. The study was terminated early due to the occurrence of significantly more thromboembolic events and excessive major bleeding with dabigatran compared with warfarin. These data resulted in revision of the US dabigatran prescribing information to include a contraindication in patients with mechanical prosthetic valves.
Prosthetic valve thrombosis
Note the following:
Surgery had historically been the mainstay of treatment but is associated with a high mortality rate.
Mortality rates of 18% have been reported in those with New York Heart Association (NYHA) class IV undergoing surgery for left-sided prosthetic valve thrombosis.
Thrombolytic therapy may be used to treat select patients with thrombosed prosthetic valves.
Thrombolytic therapy is currently recommended over surgery for right-sided prosthetic valve thrombosis. 
Thrombolytic therapy is recommended over surgery for small left-sided prosthetic valve thrombosis (thrombus area < 0.8 cm 2). The use of heparin and serial echocardiography is also recommended in these cases to documents improvement and thrombus resolution. 
Thrombolytic therapy is recommended in large (=0.8 cm 2) left-sided prosthetic valve thrombosis when contraindications to surgery are present. 
Contraindications to thrombolysis of left-sided prosthetic valve thrombosis include the presence of a large left atrial thrombus, ischemic CVA between 4 hours and 4-6 weeks ago, and very early postoperative state (< 4 d). 
Thrombolytic therapy should always be done in conjunction with cardiovascular surgical consultation.
Patients with major anticoagulant-related hemorrhage require reversal of their anticoagulation with fresh frozen plasma and vitamin K.
The time off anticoagulants should be as short as possible to avoid valve thrombosis.
Use of recombinant factor VIIa or prothrombin complex concentrate should not be used to reverse excessive anticoagulation in patients with prosthetic heart valves.
Based on findings from a retrospective study of 778 patients, Yaffee et al recommend extending established guidelines for blood conservation strategy (BCS) in routine cardiac surgeries to aortic valve replacement.[21, 22] The investigators reported that implementing BCS (eg, limits on intraoperative hemodilution, tolerance of perioperative anemia, blood management education of the cardiac surgery team) may reduce the use of red blood cells (RBCs) during surgery—without increasing mortality or morbidity.[21, 22]
In their study, implementation of the strategy resulted in a 2.7-fold reduction in RBC transfusions as well as a 1.7-fold reduction in the incidence of major complications (eg, sepsis, respiratory failure, renal failure, death).[21, 22] The incidence of RBC transfusion fell significantly from 82.9% before use of BCS to 68.0% after implementation of the strategy.
Transfusion of 2 or more units of RBC on the day of surgery was associated with mortality, prolonged intubation, postoperative renal failure, and an increased incidence of any complication. Factors that affected the risk of RBC transfusion included the following[21, 22] :
Decreased risk: Isolated aortic valve replacement, minimally invasive approach, BCS
Increased risk: Older age, previous cardiac procedure, female sex, smaller body surface area
In patients presenting with any degree of prosthetic valvular failure, early consultation with a cardiologist is recommended in order to perform and interpret an echocardiogram.
Consult a cardiothoracic surgeon early in cases of severe hemodynamic compromise.
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